Nephro Nursing:

Urinary and Renal

Dysfunctions
Trisha Isabel F. Guioguio, RN, MAN
OBJECTIVES:
Student is able to:

1. Formulate plan of care by managing patients with urinary

and renal problems.

2. Formulate health preventive measures among different

age.

3. Compare Urinary retention to urinary Incontinence and its

types
 URINARY
TRACT
INFECTION
URINARY TRACT INFECTION (UTI)

● Lower or Upper Urinary Tract Infection

● Bacteriuritis, Asymptomatic Bacteriuritis,
Bacterial Cystitis, Urethritis, Pyelonephritis, &
Prostatitis etc.
● May be classified as uncomplicated or
complicated depending on whether it is Initial
or Recurrent, Acute or Chronic.
URINARY TRACT INFECTION (UTI)
● Lower Urinary Tract Infection
○ cystitis (inflammation of the bladder)
○ bacterial prostatitis (prostate gland),
○ bacterial urethritis (urethra)
● Upper Urinary Tract Infection
○ acute or chronic pyelonephritis (inflammation
of the renal pelvis)
○ interstitial nephritis (kidneys)
○ Renal abscesses
Lower Urinary Tract Infections
● Risk Factors:
○ Inability or failure to empty the bladder
completely
○ Obstructed urinary flow
○ Decreased natural host defenses or
immunosuppression
○ Instrumentation of the urinary tract
○ Inflammation or abrasion of the urethral
mucosa
https://youtu.be/sCQQsJCZEVI
Lower Urinary Tract Infections
● Pathophysiology
Bacterial Invasion of the Urinary Tract
Urethrovesical reflux
Uropathogenic Bacteria

Entry of Pathogen/Bacteria into the Urinary Tract:

Routes: Transurethral, Hematogenous, Fistual (Intestinal)

Growth/Spread of bacteria = Infection

Lower Urinary Tract Infections
● Clinical Assessments:
● Subjective
○ Focused past health history
○ Current history
○ Medications
○ Personal data
● Objective Data:
○ Systemic and Urinary
○ Laboratory findings
Lower Urinary Tract Infections
● Clinical Manifestations:
○ Dysuria
○ Frequency
○ Urgency
○ Hesitancy
○ Cloudy, bad smelling, or bloody urine
○ Lower abdominal pain
○ Mild fever (less than 38.3° C [101° F]), chills,
and not feeling well (malaise)
Lower Urinary Tract Infections
● Laboratory Tests:
○ Urinalysis - bacteruria and pyuria.
○ Urine Cultures
○ Dipstick Nitrites Tests
● Further Tests:
○ Renal and bladder ultrasound
○ VCUG
○ IVP
○ CT Scan
Lower Urinary Tract Infections
● Medical Management:
○ Pharmacologic Therapy
■ Acute:
● Antibiotic
○ Cephalosporin (first generation)
Cephalexin, Ampicillin, Amoxicillin,
Cotrimoxazole, Ciprofloxacin, etc
■ Long-Term
○ Patient Education
Lower Urinary Tract Infections
● Nursing Diagnosis
○ Acute pain related to infection within the Urinary Tract
○ Deficient knowledge about factors predisposing the
patient to infection and recurrence, detection and
prevention of recurrence, and pharmacologic therapy
○ Infection related to frequency or burning on urination,
fever, elevated white blood cell count, foul-smelling
urine, and suprapubic tenderness
○ Impaired urinary elimination related to excessive
urgency and pain with bladder filling
Lower Urinary Tract Infections
● Planning and Goals:
○ Relief of pain and discomfort,
○ Increased knowledge of preventive measures and
treatment modalities
○ Absence of complications
○ Eradicate pathogenic organisms in the person’s
urine
○ Prevent the recurrence of infection.
Lower Urinary Tract Infections
● Nursing Interventions
○ Relieving Pain
■ Antispasmodic, Analgesic
■ The patient is encouraged to drink liberal
amounts of fluids
■ Urinary tract irritants (eg, coffee, tea, citrus,
spices, colas, alcohol) are avoided.
■ Encourage Frequent voiding (every 2 to 3 hours)
Lower Urinary Tract Infections
● Nursing Interventions
○ Monitoring and Managing Potential Complications
■ Teach patient to recognize early signs and
symptoms
■ If an indwelling catheter is necessary
● Use strict aseptic technique
● Securing the catheter with tape
● Frequently inspecting urine color, odor, and
consistency
● Perineal Hygiene
Lower Urinary Tract Infections
● Patient Education
○ Hygiene
○ Fluid Intake
○ Voiding Habits
○ Adherence to Therapy
Lower Urinary Tract Infections
● Evaluation:
○ Expected patient outcomes may include:
■ Experiences relief of pain
■ Explains UTIs and their treatment
■ Experiences no complications
Upper Urinary Tract Infections
● Pyelonephritis
○ is a bacterial infection of the renal pelvis, tubules,
and interstitial tissue of one or both kidneys
○ Causes:
■ Transurethral spread of bacteria
■ Systemic Spread
■ Bladder tumors
■ BPH
■ Urinary stones
■ Systemic infections
https://youtu.be/FcRjFhMvaTo
Acute Pyelonephritis
● Clinical Manifestations
○ Fever and Chills
○ Tachycardia and Tachypnea
○ Nausea
○ Flank Pain on the affected sife
○ Costovertebral angle Tenderness
○ Headache
○ Dysuria, Frequency and urgency urination
○ Cloudy, bloody, foul-smelling urine
○ WBC in urine
Acute Pyelonephritis
● Diagnostic Findings:
○ Ultrasound study or CT Scan may show
obstruction
○ IV Pyelogram may be prescribed in functional
or structural renal abnormalities are suspected
○ Urine culture and sensitivity
Acute Pyelonephritis
● Medical Management
○ Uncomplicated: May be treated Outpatient
○ Pregnant - Hospitalized for 2-3 days, on
parenteral anitibiotic therapy
○ Hydration (may be oral or parenteral)
Chronic Pyelonephritis
● Clinical Manifestations
○ Usually has no symptoms of infection unless an
acute exacerbation occurs.
○ Signs and symptoms may include:
■ Fatigue, headache, poor appetite, polyuria,
excessive thirst, and weight loss.
■ Mild, intermittent fever or intermittent back or
flank pain may accompany the urinary symptoms
○ Persistent, recurring infection may result in renal
failure
Chronic Pyelonephritis
● Diagnostic Findings:
○ Extent of the disease can be assessed by:
■ IV urogram and measurements of creatinine
clearance, blood urea nitrogen, and
creatinine levels.
○ Urinalysis and urine culture
■ Bacteruria
○ CT Scan - diagnose obstructive etiology
Acute or Chronic Pyelonephritis
● Nursing Diagnosis
○ Risk for imbalanced body temperature
○ Pain related to ureteral colic
○ Fear in response to the diagnosis of pyelonephritis
○ Deficient knowledge related to completion of drug
○ therapy, optimal fluid intake, or need to empty
bladder every four hours to reduce bacterial count
○ Ineffective coping related to anxiety, malaise (body
discomfort and fatigue), and lowered activity level
Acute or Chronic Pyelonephritis
● Planning
○ Eradicate UTI
○ Preventing further infection
● Evaluation of Outcomes
The patient:
■ maintains body temperature within a normal range
■ manifest positive coping behaviors
■ Identifies support systems
■ verbalize maintenance of identified comfort level.
■ verbalize the drug therapy regimen and the need to
complete the full dose on schedule
DYSFUNCTIONAL
VOIDING
PATTERNS
https://youtu.be/J2AgZE5kTUU
Voiding Dysfunctions
● Urinary Retention and Urinary Incontinence
● Conditions causing adult voiding dsyfuntions:
○ Neurogenic Disorders
■ Cerebellar ataxia, CVA, Dementia, Diabetes,
Multiple sclerosis, Parkinson’s disease
○ Spinal Cord Dysfunction
■ Acute injury, Degenerative disease
○ Non-Neurogenic Disorders
■ “Bashful bladder”, Overactive bladder,
Post-general surgery, Post-prostatectomy
Urinary Retention
● Inability to empty the bladder completely during
attempts to void.
● Chronic urine retention often leads to overflow
incontinence
○ pressure of the retained urine in the bladder
● Residual urine - urine that remains in the bladder
after voiding
Urinary Retention
● Etiology
○ Blockage of Urethra
■ Stones, fecal impactions, prostate
enlargement, urethral rupture, tumor or clots
in the bladder
○ Drugs (antihistamines, ephedrine sulfate,
phenylpropanolamine)
Urinary Retention
● Clinical Manifestation
- acute onset pain of intolerable severity
- Chronic cases - patients do not experience pain
- increasing dull low abdominal discomfort
- urge to urinate
- Palpation: firm, distended bladder
- Hematuria (may also develop)

Chronic retention
- Urinary Frequency rather than inability to urinate
Urinary Retention
● Diagnostic Tests
○ Urinalysis may give a clue to underlying UTI
○ BUN and serum creatinine may reflect acute renal
failure
○ WBC: raised in prostatitis and UTI
○ Urinalysis and electrolytes are essential as renal
failure often follows chronic retention; if urinary
calculus, check urate, calcium, and phosphate
○ Check PSA in prostatic enlargement for carcinoma
○ Renal ultrasound, IVP, urethrography
Urinary Retention
● Nursing Diagnosis
○ Urinary retention
○ Acute pain as related to acute urinary
retention
● Planning and Implementation
○ Initial management should be urethral
catheterization
○ High risk: encourage patient to pass urine
■ Every 3 to four hours
https://youtu.be/srX7u69aL3E
Urinary Retention
● Evaluation of Outcomes
○ Urinary retention. The patient empties the
bladder completely and has a residual of less
than 30 mL.
○ Acute pain as related to acute urinary
retention. The patient should verbalize an
adequate relief of pain along with the ability to
realistically cope with the pain if it is not
completely relieved
Urinary Incontinence
- loss of bladder control, involuntary passage of urine

Etiology
Sudden or temporary incontinence
- UTI, prostate infection, stool impaction, Medications,
Poorly controlled diabetes Pregnancy
Causes for long-term UI
- spinal injuries, urinary tract anatomical abnormalities,
CVA, benign prostatic hypertrophy, pelvic prolapse in
women, and bladder cancer
Urinary Incontinence

Types:
1.Stress Incontinence
2.Urge Incontinence
3.Overflow Incontinence
4.Functional Incontinence
Urinary Incontinence: Types

Stress Incontinence
- is loss of urine with increased intra-abdominal
pressure without detrusor contraction
- happens when urine leaks during exercise,
coughing, sneezing, laughing, lifting heavy
objects, or other body movements that put
pressure on the bladder
https://youtu.be/dd1iVW3zFik
Urinary Incontinence: Types
Urge Incontinence
- Involuntary loss of urine preceded by a strong
urge to void, with increased intravesical pressure
and detrusor contraction.
- An uninhibited detrusor contraction is the
precipitating factor.
- Common among patients with diabetes, stroke, or
- Early sign of bladder cancer.
https://youtu.be/CDDEVnim_fo
Urinary Incontinence: Types
Overflow Incontinence
- loss of urine because of chronic urinary retention or
secondary to a flaccid bladder

Functional Incontinence
- normal bladder control
- People who have a hard time getting to the toilet in time
because of arthritis or other disorders that make moving
quickly difficult.
Urinary Incontinence: Types
Iatrogenic Incontinence
- involuntary loss of urine due to extrinsic medical factors,
predominantly medications
- Mimicking stress incontinence

Mixed urinary incontinence

- which encompasses several types of urinary
incontinence, is involuntary leakage associated with
urgency and also with exertion, effort, sneezing, or
coughing
https://youtu.be/rQQSqLCF12g
Urinary Incontinence
Clinical Manifestations
- Assessment include neurologic examinations (even
psychiatric) - Goal - to rule out underlying conditions.
- Asses flank area for masses, distended bladder after
voiding
- Signs of fluid overload.
- A stress test can assess for stress-induced leakage
when the bladder is full.
- patient to cough or strain once vigorously;
instantaneous leakage is typical of stress UI
Urinary Incontinence
Diagnostic Tests
-urinalysis, urine culture
-cystoscopy, urodynamic studies
-post void residual (PVR)
https://youtu.be/4Zp4ksJdgQo
Urinary Incontinence
Nursing Diagnosis
- Impaired urinary elimination
- Deficient knowledge related to self-care and risk
Prevention
Planning and Implementation
- Behavioral techniques
- Devices
- Medications
- Surgery
Urinary Incontinence
Pharmacological Management
-Anticholinergics (Oxybutynin)
-Antidepressants (Imipramine Tofranil)
-Hormone replacements
-Antibiotics
Urinary Incontinence
Evaluation of Outcomes
● Impaired urinary elimination.
○ The patient is continent of urine or verbalizes
satisfactory management
● Knowledge deficit related to self-care and risk
prevention.
○ The patient should demonstrate motivation to learn,
identify perceived learning needs, and verbalize an
understanding of desired content.
https://youtu.be/SWLv9gd8w80
Neurogenic Bladder
- dysfunction that results from a lesion of the nervous
system and leads to urinary incontinence.
- Causes:
- spinal cord injury, spinal tumor,
- herniated vertebral disk, multiple sclerosis,
congenital disorders (spina bifida or
myelomeningocele), infection,
- complications of diabetes mellitus
Neurogenic Bladder
Spastic (Reflex Bladder)
- spinal cord lesion above the voiding reflex arc
- loss of conscious sensation and cerebral motor control.

Flaccid Bladder
- lower motor neuron lesion (common from trauma)
- The bladder continues to fill and becomes greatly
distended, and overflow incontinence occurs
https://youtu.be/FfoMsi7qdhQ
https://youtu.be/QZ9N4RmCEJc
Neurogenic Bladder
Assessment:
- measurement of fluid intake, urine output, and
residual urine volume
- Urinalysis
- Assessment of sensory awareness of bladder
fullness and degree of motor control
- Urodynamic Studies
Neurogenic Bladder
Medical Management:
- Long-Term Goals:
- Prevent overdistention of bladder
- Emptying regularly and completely, maintaining urine
sterility
- Maintaining adequate bladder capacity
- Pharmacologic Therapy
- Parasympathomimetic medications
- Surgical Management
end.